Healthcare Provider Details

I. General information

NPI: 1891731741
Provider Name (Legal Business Name): INTEGRATED MEDICAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 BUSTLETON AVE SUITE A
PHILADELPHIA PA
19116-1187
US

IV. Provider business mailing address

15501 BUSTLETON AVE SUITE A
PHILADELPHIA PA
19116-1187
US

V. Phone/Fax

Practice location:
  • Phone: 215-742-7033
  • Fax: 215-742-7034
Mailing address:
  • Phone: 215-742-7033
  • Fax: 215-742-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: NATALYA MATYASHOVA
Title or Position: COORDINATOR
Credential:
Phone: 215-742-7033